Clinical Playbook · Meibomian Glands
Meibomian gland expression is a diagnostic step and a first-line treatment in one. Grade what the glands yield, stage the MGD, then clear the obstruction so the glands can resume normal function. In-office expression has at least an 80-year history.
Obstructed glands hold thickened meibum that will not flow on its own. Diagnostic expression shows how far the dysfunction has gone; therapeutic expression clears it.
Done first, to confirm MGD and stage its severity. Press and hold a finger or cotton-tip applicator against the lower lid for about 5 to 15 seconds and watch the gland orifices at the slit lamp. The central to nasal lower lid is the most informative area.
A more complete expression of every gland to evacuate the obstruction so the gland can resume normal function. Warm first, then press the lid against a rigid backstop on the inner lid surface, which protects the globe and lets more force reach the glands.
Meibomian Gland Evaluator
Finger and cotton-tip pressure changes from one examiner, and one visit, to the next. The Meibomian Gland Evaluator applies a standard, spring-calibrated force of 1.25 g/mm² over 40 mm², about eight glands, which approximates the force the lids apply during a natural blink. A gland that yields liquid oil at that force is a functioning gland.
Do not depress the shaft to the endpoint of the spring or add force after it has been depressed about 6 mm. Disinfect with alcohol between patients.
Grading
The MGD Workshop scales score meibum quality and expressibility separately. Record both at baseline and at every follow-up.
Each of eight glands in the central third of the lower lid, scored 0 to 3. Total 0 to 24.
Five glands of the lower or upper lid, scored by how many express.
No meibum with clear orifices may mean the glands have atrophied; therapeutic expression will yield little, and meibography shows how much gland remains.
The MGD Workshop staged algorithm builds treatment up as expressibility, meibum quality, symptoms and staining worsen.
| Stage | MGD grade | Symptoms and staining | Treatment |
|---|---|---|---|
| Stage 1 | Minimally altered expressibility and secretion quality | No symptoms; no corneal staining | Inform the patient about MGD, diet, environment and drying medications. Consider eyelid hygiene, including warming and expression. |
| Stage 2 | Mildly altered expressibility and secretion quality | Minimal to mild symptoms; none to limited staining | Eyelid warming for a minimum of four minutes, once or twice daily, followed by moderate to firm massage and expression. Consider lubricants and other topical therapy. |
| Stage 3 | Moderately altered expressibility and secretion quality | Moderate symptoms; mild to moderate, mainly peripheral staining | All of the above, plus oral tetracycline derivatives, bedtime lubricant ointment and anti-inflammatory therapy as indicated. |
| Stage 4 | Severely altered expressibility and secretion quality | Marked symptoms; marked staining, central in addition | All of the above, plus anti-inflammatory therapy for dry eye. |
Plus disease, such as Demodex-related anterior blepharitis, chalazion or anterior blepharitis, can occur at any stage and is treated alongside. For Demodex blepharitis, see XDEMVY ›
The procedure
Expression outside the slit lamp gives more freedom of movement; magnification is still needed to diagnose.
Apply a warm compress for about 10 minutes before therapeutic expression to soften the meibum. A drop of topical anesthetic is usually not needed for diagnostic expression but may help for extensive therapeutic expression.
Have the patient look up for lower lid expression and down for upper lid expression.
Starting nasally, pull the lid down to expose the gland orifices and palpebral conjunctiva. Place a paddle or saline-moistened cotton tip on the palpebral conjunctiva midway between the fornix and the lashes, then press the outer lid with a second applicator and roll or rock from the base of the glands toward the orifices. Move section by section across the lid.
With the patient looking down, lift the lid slightly off the globe, insert the cotton tip or paddle midway between the superior fornix and the lashes, and roll or rock downward to express. Repeat across the lid.
Artificial tears in the office soothe the palpebral conjunctiva. Set expectations: one expression is not a permanent cure, and MGD needs long-term management at home.
Technique adapted from Hatley and Lighthizer, Review of Optometry; force thresholds from the MGD Workshop management report.
TFOS DEWS III lists device-driven lid warming, intense pulsed light and low-level light therapy among in-office MGD treatments.
Expressor forceps and standardized diagnostic expression in the office, warming and lid hygiene for the patient's daily routine.
Meibomian Gland Expressor Forceps, Flat TipArriving shortly
Meibomian Gland Expressor Forceps, Round TipArriving shortly
Meibomian Gland EvaluatorView product
Meibomian Gland Grading Scale, Framed CanvasView product
Bruder Moist Heat Eye CompressView product
Bruder Hygienic Eyelid Care KitView product
Diagnostic expression is a short, held press on the lower lid to see what the glands yield and grade it. Therapeutic expression is a more complete expression of all glands, usually after warming, to clear the obstruction.
In the MGD Workshop scheme, meibum quality is scored 0 to 3 in each of eight glands of the central third of the lower lid (0 clear, 1 cloudy, 2 cloudy with debris, 3 thick like toothpaste; total 0 to 24). Expressibility is scored 0 to 3 across five glands (0 all expressible, 1 three to four, 2 one to two, 3 none).
It applies the same spring-calibrated force of 1.25 g/mm² over about eight glands every time, approximating the force of a natural blink. The count of glands yielding liquid secretion at that force reflects how many glands work during everyday blinking, and it is comparable from visit to visit and examiner to examiner. Standardized instrumentation for diagnostic expression has been described as desirable if not mandatory.
If no meibum appears and the orifices look clear, the glands may have atrophied, and therapeutic expression will yield little. Meibography shows how much gland structure remains.
Force is usually limited by pain rather than by what can be applied. Pain rises rapidly above about 15 g/mm² (about 5 PSI), and forces of 80 g/mm² (about 25 PSI) or more frequently produce excruciating pain. A rigid backstop on the inner lid protects the globe.
Usually not for diagnostic expression. A drop of topical anesthetic may be warranted for more extensive therapeutic expression, depending on the patient.
The MGD Workshop staged algorithm calls for eyelid warming for a minimum of four minutes, once or twice daily, followed by moderate to firm massage and expression, from stage 2 onward.
Techniques range from cotton-tip applicators to expressor paddles placed inside the lid and forceps-style expressors for one-handed use. Dry Eye Rescue carries the Meibomian Gland Evaluator for standardized diagnostic expression, plus warm compresses and lid hygiene for home care. Flat-tip and round-tip expressor forceps are coming soon.
Thermal pulsation, lid heating systems, intense pulsed light and low-level light therapy all target MGD. TFOS DEWS III lists device-driven lid warming, IPL and LLLT among in-office MGD treatments.
Grade the glands at baseline, treat the obstruction, and keep patients warming and cleaning between visits.
This page summarizes published clinical guidance for eye care professionals and does not replace clinical judgment. Product names are trademarks of their respective manufacturers. Review each manufacturer's instructions for use before use.
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